Fighting malnutrition with “dysfunctional” health sector

Hovering at around 20 percent in some places, Kanem Region in western Chad is well-known for having some of the world’s highest continual severe acute malnutrition rates. “Emergency” aid agency malnutrition responses have continued year on year since the 1980s.

Part of the problem is due to chronic food insecurity and drought that has affected much of the Sahel this year: This year some 3.6 million Chadians are food insecure due to poor rains, according to the World Food Programme. Dangerous care practices also play their role: Giving babies dirty water instead of breast milk, burning their chests when they have diarrhoea, among others.

But unless something is done to improve the country’s “dysfunctional” health system (as described by half a dozen interviewees), these malnutrition rates are unlikely to change significantly.

IRIN spoke to Ministry of Health staff, aid workers, government officials and mothers to find out if anything can be done to wean Chad from its dependence on emergency nutrition interventions.

"What doesn't need fixing?"

Taking a tour of the district hospital in Mao - one of two in Kanem Region - it quickly becomes clear the structure is a hospital in name only: most of the rooms are empty, without equipment, and there are few health staff around, other than in the aid agency-supported nutrition wing.

This low capacity is region-wide. Kanem has just six doctors for 410,385 people, according to the health district’s nutrition focal point, Maina Mahamat Abakar Sadick; 65 percent of health clinics are not operational because they have no staff; over half are run by someone unqualified to do so; and 65 percent of them are made of non-durable materials. One in four has no cold-chain facilities and so cannot administer routine vaccinations. As one nutrition expert put it: “What doesn’t need fixing?”

Nutrition, as a sub-set of the health sector, is de-prioritized and poorly understood, according to Dallam Adoum, who runs the Ministry’s of Health’s Centre of Nutrition and Technology (CNTA), which covers everything from prevention to treatment of malnutrition, and was set up before 1960 but still has no budget.

According to him, there are just 15 nutritionists officially working in the Health Ministry - excluding those who have been trained by aid agencies.

Understanding of the causes of malnutrition is pretty low within the Ministry, said Adoum.

This was backed up by Céline Bernier, nutrition coordinator at Action Against Hunger (ACF), who said little nutritional surveillance takes place other than that carried out by aid agencies (such as ACF, UNICEF, Médecins Sans Frontières and Worldvision, among others.) “The government recognizes there is a problem but it doesn’t necessarily know how to fix it,” she told IRIN.

Things, not people

When the government does invest (5-6 percent of the annual budget is spent on health, according to UNICEF), it tends to focus on “things” rather than people and processes, several analysts told IRIN. “The main problem is human resources,” said Roger Sodjinou, nutrition manager for UNICEF in Chad. “There is no clear idea of the HR strategy of the government.”

Francois Ndoubalhidi who runs the ostensibly independent organization to monitor the country’s petrol resources (CCSRP), says the same is true for the estimated US$1.9 million of petrol funds that are, according to him, directed to the health sector each year.

“The government is more into concrete investments - building health clinics for instance - human resources is not a priority,” he told IRIN.

Building up pools of trained staff requires vision and planning, but most of the 22 regional governments have no nutrition or health plans, according to a nutrition expert at one large aid agency, and “even national plans are not very clear.”

Due to support from aid agencies, 261 health centres across ten regions are now treating acute and severe malnutrition according to UNICEF. But this number must double to reach the 127,000 children expected to suffer acute severe malnutrition over the next six months, said UNICEF head Bruno Maes.

Picking up the pieces

On the nutrition front, aid agencies for the most part pick up the pieces, treating acutely malnourished children all over the country’s Sahelian zone - though gaps remain in parts of several districts, according to EU humanitarian aid body ECHO.

The number of acutely malnourished children being admitted to ACF and UNICEF’s therapeutic feeding and treatment centres at the district hospital in Mao has shot up in recent months, according to Bernier and UNICEF’s nutrition coordinator in Mao, Augustin Ilunga.

A nurse at Mao district hospital registers new patients into the nutrition wing

In 2011 they treated 14,400 severely malnourished children, and as of the end of February had already treated 2,000. “It looks like the numbers will be even higher this year,” he told IRIN.

Women come from all over the region to treat their children. Harmatta Ousmane,17, brought her 10-month-old son Abakar from the neighbouring sub-district of Kékédiné, after hearing about the Mao centre through neighbours. “I am learning a lot here about how to feed children - what food to give them, to boil water if they need to drink it,” she told IRIN.

However, many mothers often head too late to the centre so their children die en route - health clinics may take far too long to refer them, said Seydou Dicko, head of the ACF nutrition programme in Mao, or mothers go to the health clinic too late because they prefer to visit traditional healers.

These “healers”, however, often end up inflicting tremendous harm, said UNICEF’s Ilunga, burning children when they vomit or have diarrhoea; cutting off a part of their mouth when they have a cough; and pulling out their baby teeth when they are sick. “These healers are brutal, they do not understand the importance of diet or vaccinations,” said Naga Tibé who, as a member of a women’s association in Mao, tries to warn people against visiting them.

But while part of the solution lies in education and convincing families to change, unless health clinics are operational, many women have no alternative, they told IRIN.

Aid agencies are trying to boost government capacity. ACF trains and pays district health staff in nutrition prevention and care, and then tries to reintegrate them into the district health system - 28 have been reintegrated thus far.

UN and donor partners have helped the government develop a recruitment strategy, which aims to boost health staff by 1,000 countrywide this year. UNICEF’s role in this is to help the government recruit and deploy 400 parademics to regions in the Sahel belt.

People working to develop Chad’s water and sanitation sector - lack of drinking water and latrines has a big impact on children’s nutrition - now work hand in hand with nutritionists, and UNICEF is pushing for all health clinics to at least have latrines and running water (over half currently have no water source). Incremental progress in the water and sanitation sector should also improve nutrition statistics, some staff say: the government will sign off on its first sanitation strategy in April, and for the first time has set aside a national budget for sanitation.

The Health Ministry should take note and develop a malnutrition prevention and treatment strategy, with its own budget line, say aid agency staff. “We must profit from the current political stability to progress on malnutrition,” said UNICEF’s Maes.

The ministry could increase its nutrition performance by increasing its recruitment budget so there is at least one state-registered nurse at each health centre; include it in basic medical training; and up the number of places available in medical schools, said Bernier.

“Everything is a question of priority… Malnutrition is rarely a priority for men in power. Health care is expensive, and the more you develop your health system, the more expensive it gets… but there are also economic dividends, at least in the long term.”

The ministry can do little to impact the increasing frequency of droughts decimating harvests in the Sahel, but it can at least do what it can to improve its own systems. If not, said Ilunga, “We’ll just be here giving Plumpy’nut forever.”

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